Maternal Perceptions of Evidence-Based Early Childhood Sleep Health Promotion Recommendations: An Explanatory Sequential Study

Abstract

Objectives:

The purpose of this explanatory sequential design study was to better understand caregivers’ perceptions about and interest in evidence-based early childhood sleep health promotion recommendations.

Method:

A purposeful sample of mothers of 20 1–5-year-old children (10 children exhibiting optimal sleep and 10 children exhibiting insufficient/fragmented sleep) attending a preschool serving a low socio-economic (SES) status metropolitan community were invited to participate in qualitative interviews. Data were coded according to a grounded theory approach and themes were identified within the optimal and suboptimal sleeper groups.

Results:

Mothers reported different approaches to managing electronics by optimal/suboptimal sleeper group, with mothers of optimal sleepers limiting access to electronics more than mothers in the suboptimal sleep group. Other themes of sleep health practices did not differ meaningfully between groups.

Conclusions:

Maternal perspectives about early childhood sleep health were similar across optimal and suboptimal sleepers on most elements of child sleep health. Managing child sleep was contextually influenced and these results highlight the complexities of how families living in lower SES environments perceive common sleep recommendations. Thus, sleep health education efforts should be tailored to the needs and values of specific families and communities.

Behavioral sleep problems are common in early childhood, occurring in roughly one-quarter of children (Owens et al., 2011) and persisting from infancy to middle childhood in about 8% of children (Williamson et al., 2019a). Insufficient sleep durations relative to age-based recommendations are also highly prevalent in early childhood, occurring in roughly one-third of toddlers and preschoolers (Pena et al., 2016; Williamson & Mindell, 2020). Socio-demographic factors may contribute to variations in sleep problems in early childhood. Compared to non-Hispanic/Latinx White children (hereafter, ‘White’), children from Hispanic/Latinx and/or African American/Black backgrounds living in the US are more likely to go to bed later and receive shorter, less regular sleep (Smith et al., 2019). Furthermore, children living in lower socioeconomic status (SES) homes (Zhang et al., 2021) and neighborhoods (Williamson et al., 2021) exhibit a greater likelihood of insufficient sleep and frequent night awakenings. At the same time, some research suggests that families living in lower SES neighborhoods report fewer child sleep problems and more confidence managing child sleep relative to those in more advantaged neighborhoods (Williamson et al., 2021).

Variations in caregiver perceptions of behavioral sleep problems according to SES may be related to family knowledge about child sleep needs (McDowall et al., 2017). In a study of infants, those who received insufficient sleep were more likely to have a caregiver with lower health literacy (Bathory et al., 2016), although more research is needed. Another study qualitatively identified that mothers may focus on other more salient parenting and/or social concerns than infant sleep duration (Zambrano et al., 2016). Neighborhood-level differences in child sleep duration are clinically significant though, amounting to approximately 3.5 hours less sleep per week in lower SES neighborhoods compared to higher SES counterparts (Williamson et al., 2021). As insufficient and poor quality sleep has been associated cross-sectionally and longitudinally with adverse child developmental outcomes (Matricciani et al., 2019; Taveras et al., 2017), methods to promote healthy sleep in early development for all young children are especially important. Thus, understanding the drivers of caregiver-reported child sleep problems is crucial for family-centered sleep health promotion approaches.

Qualitative research can reveal the nuances of how caregivers think about and manage their young child’s sleep. In prior qualitative research, caregivers consistently reported valuing sleep for their children and themselves (Coldwell et al., 2006; Lindsay et al., 2018; Sadler et al., 2020). Across these studies, families living in lower SES contexts have identified environmental barriers to healthy sleep practices, such as neighborhood noise and violence, shared living conditions, and caregiver work schedules (Lindsay et al., 2018; Sadler et al., 2020). While caregivers have highlighted co-sleeping arrangements (bed- and/or room-sharing), which can be linked to family values and culture, as beneficial to sleep and the caregiver/child relationship, some have identified these arrangements as disrupting the caregiver’s sleep (Caldwell et al., 2020).

Some of the variability in the endorsement of child sleep problems may be due to the specific elements of sleep that are assessed (Honaker et al., 2021). In a large study of infants and toddlers from lower-SES neighborhoods, 7.4% of caregivers reported a child sleep problem, while almost three-quarters of families reported needing to manage their child’s nighttime awakenings. This finding suggests that many young children may exhibit sleep behaviors amenable to intervention, but caregivers may not consider these behaviors as problematic or perceive awakenings as modifiable (Honaker et al., 2021). Cross-cultural research also suggests that expectations about child sleep patterns and aspects of the sleep ecology, including co-sleeping practices and caregivers’ bedtime behaviors, may be linked to the family’s culture (Mindell et al., 2010; Zreik et al., 2020).

Caregivers’ knowledge about child sleep and sleep problem perceptions also contribute to their likelihood of reporting sleep concerns, which in turn influences whether they receive sleep-related resources (Honaker et al., 2021). Variability in caregiver knowledge about child sleep, including recommended sleep duration and the impact of other sleep-related behaviors on sleep health, such as bedtime electronics and caffeine consumption may also contribute to caregiver-perceived child sleep difficulties (Sadler et al., 2020; Williamson et al., 2020). A recent qualitative study of young children with caregiver-identified sleep problems highlighted caregivers’ desire to receive this sleep health guidance as part of their child’s healthcare (Williamson et al., 2020). However, a recent meta-analysis indicated that sleep knowledge is related to child sleep health practices but not total sleep duration (Zhang et al., 2021). Thus, knowledge is important but may not be sufficient in supporting caregivers in sleep health promotion efforts. Furthermore, perceptions about common sleep health recommendations have not been assessed in young children without caregiver-identified sleep problems.

The current study sought to identify child sleep health needs in a large, metropolitan preschool that serves primarily African American/Black and Hispanic/Latinx children in Camden, New Jersey where many families live in lower SES neighborhoods. The purpose of this explanatory sequential mixed methods design study was to better understand whether caregivers’ perceptions about and interest in evidence-based early childhood sleep health promotion recommendations (Allen et al., 2016) vary according to quantitatively defined optimal versus less desirable child sleep health practices. Based on their quantitative reports of child sleep, caregivers were purposefully sampled (Palinkas et al., 2015) to represent those with differences in child sleep health practices to participate in qualitative interviews to understand the challenges caregivers face with their child’s sleep and acceptability of standard child sleep recommendations. Caregivers were identified according to common research-based indicators of child sleep health that are associated with child development: sleep duration and consolidation (Matricciani et al., 2019; Taveras et al., 2017; Touchette et al., 2007). We hypothesized that themes regarding child sleep health management would differ based on the quantitatively defined optimal versus less desirable sleep health group.

Methods

Participants and Design

Families were recruited from a university-affiliated preschool program whose mission is to “prepare at-risk children for academic success.” Quantitative data on child sleep patterns was collected in 2018. Of 214 eligible 1–5-year-old children enrolled in the preschool program, caregivers of 141 children completed surveys. This study used an explanatory sequential mixed methods design (Creswell & Clark, 2017) with qualitative data to support a deeper understanding of quantitative profiles of optimal and suboptimal child sleep patterns. After quantitative data collection, we invited a purposeful sample (Palinkas et al., 2015) of caregivers of 10 children who reported optimal sleep (adequate sleep duration or no night awakenings) and 10 children who exhibited insufficient/fragmented sleep (insufficient sleep duration for age or 1 or more night awakenings) to participate in qualitative interviews. The final sample size of 20 was initially determined a priori based on sample size recommendations for qualitative data saturation (Strauss & Corbin, 1990). We then confirmed by group consensus that saturation had been reached with the current study’s sample size, as no new themes emerged during data coding. All caregivers (“mothers”) who participated in qualitative interviews were biological mothers and most were African American/Black or Hispanic/Latinx (Table 1).

Table 1.

Sample Sociodemographics.

		N	%	M (SD)	Suboptimal Sleepers	Optimal Sleepers
Caregiver Age				32.22 (6.33)	31.33 (5.65)	33.37 (7.41)
Caregiver Sex	Female	20	100		10	10
Caregiver Race & Ethnicity	Black	13	65		6	7
	Hispanic/Latinx	5	25		3	2
	White	1	5		1
	Black and Hispanic/Latinx	1	5		1	1
Caregiver Highest Education	High School/GED	6	30		3	3
	Associates	4	20		1	3
	Vocational	1	5		1	0
	College	8	40		5	3
	Graduate	1	5		0	1
Child Age				3.35 (1.1)	3.42 (1.08)	3.27 (1.17)
Child Sex	Female	10	50		5	5
	Male	10	50		5	5
Child Race & Ethnicity	African American	11	55		6	5
	White and Asian American	1	5		1	0
	Hispanic/Latinx	2	10		0	2
	Black and White	1	5		0	1
	Black and Hispanic/Latinx	5	25		3	2

Procedures

The study was approved by the Rutgers University Institutional Review Board (Protocol # 20170001317). Caregivers provided informed consent prior to quantitative data collection and again at the qualitative interview visit. Data collection procedures for the quantitative study have been reported previously (Daniel et al., 2020). Caregivers completed the Brief Child Sleep Questionnaire (BCSQ) as part of the quantitative data collection (Kushnir & Sadeh, 2013; Sadeh et al., 2009). The 30-item questionnaire asks caregivers about their child’s sleep times, routines, nighttime awakenings, and difficulty managing the child’s sleep. BCSQ questions were used to purposively sample the sleep health groups described above. For total child sleep duration, caregiver responses to questions about child nighttime and daytime sleep duration were summed and dichotomized as being sufficient or insufficient according to age-based national guidelines (11–14 hours for ages 1–2 years and 10–13 hours for ages 3–5 years). Caregiver responses to a question about the frequency of child night awakenings were dichotomized according to prior research, with 1 or more per night being reflective of frequent awakenings, or more fragmented child sleep (Bernier et al., 2010), recognizing that 1 awakening is normative for some children this age but that acceptability of the awaking may differ across caregivers. Caregivers also completed a 10-item child sleep knowledge questionnaire previously used in early childhood education settings (Bonuck et al., 2016). Items are constructed as true/false statements that reflect parental knowledge of child sleep health behaviors (e.g., “Screen time before bed relaxes children so they fall asleep more easily”) and impacts (e.g., “Sleep problems are unlikely to affect a child’s social emotional development”) (internal consistency: ω =0.59 in the full quantitative sample). A total correct percent was calculated with higher scores indicating greater knowledge to describe each group’s sleep knowledge.

Semi-structured interviews were conducted by the lead author who is a licensed clinical psychologist with training in qualitative methodology (LCD) and audio-recorded in a private location at the preschool. Interviews started approximately 6 months after completing quantitative data collection. Families had not met the interviewer previously and she was not affiliated with the preschool. The interviews ranged from 20 to 95 minutes and were audio recorded. Interview participants were compensated with $20 gift cards for their time. The qualitative interview guide (see Supplemental Documents) included questions asking interview participants about their child’s sleep patterns and their perceptions of common evidence-based pediatric sleep health recommendations and behavioral sleep treatment approaches (Allen et al., 2016). The recommendations consisted of avoiding electronics in the bedroom, maintaining an “early” bedtime of 9 pm, implementing a consistent bedtime routine and schedule, falling asleep independently, and ensuring age-appropriate sleep duration. Interview participants were also asked to identify barriers and facilitators associated to implement these recommendations. Lastly, all interview participants were asked to discuss their family’s approach to co-sleeping (defined as bed-sharing in this study) and identify positive and negative elements of co-sleeping with young children.

Analytic Approach

Interviews were transcribed and checked against audio by a second team member for accuracy. Then the research team used a grounded theory approach to iteratively develop a codebook, which was then loaded into NVivo 12 and applied to the transcribed interviews. The codebook was applied to two interviews together as a team (MS, LD, LCD) and then applied to four interviews independently (MS, LD) and agreement was compared (weighted kappa =0.41–0.62). Coders were blind to optimal/suboptimal sleeper groupings. Coding disagreements were resolved together in team meetings with the lead author, with additional codebook refinement through coding an additional interview as a team. The refined codebook was re-applied to the 4 double-coded interviews (weighted kappa = 0.50–0.75) and discrepancies in coding were addressed by consensus in team meetings. We then independently double-coded 3 additional interviews using the refined codebook (weighted kappa = 0.66–0.81). The final codebook was then applied to the remaining interviews and then double-coded by a second rater. Themes were determined by consensus and compared across quantitatively identified groups of optimal and suboptimal sleepers.

Results

Descriptive

In the full sample, most families (65%) did not report any child sleep problems and 35% reported a very small to a small problem. Maternal knowledge about child’s sleep, confidence in managing child sleep, and 24-hour sleep was similar between groups (Table 2). Of families reporting suboptimal sleep health, two mothers reported insufficient sleep duration for the child’s age, five mothers indicated frequent night awakenings, and three mothers endorsed both insufficient sleep and frequent night awakenings.

Table 2.

Quantitative data by type of sleeper.

	Optimal Sleep (n=10) M (SD)	Suboptimal Sleep (n=10) M (SD)
Caregiver Sleep Knowledge, % correct	44.0% (21.7%)	52.0% (21.0%)
Total 24-hour Sleep	11.60 (1.39)	10.07 (1.32)
	n endorsing	n endorsing
Confidence managing your child’s sleep	6 (60.0%)	6 (60.0%)
Do you consider your child’s sleep a problem	2 (20.0%)	5 (50.0%)

Thematic Comparison of Sleep Health Behaviors and Sleep Ecology by Sleep Groups

Electronics.

Across all participants, mothers acknowledged the need to manage electronics in the home. Electronics were often used intentionally to give the mother time for household chores (i.e., cooking dinner), educational purposes, and to relax in the evening including to facilitate sleep. There were group differences in approaches to managing electronics. Specifically, mothers of optimal sleepers reported actively managing electronics (e.g., removing them, setting time limits) and limiting their use at bedtime and in the bedroom. Mothers of suboptimal sleepers were more likely to report that it was difficult to control evening electronics use and access. Many of these mothers expressed concern with the sleep health recommendation to remove electronics from the bedroom. Some mothers who used electronics in the bedroom acknowledged the impact of electronics on sleep, however, mothers also perceived electronics as necessary to facilitate sleep and reported that they would not consider removing electronics from the bedroom.

Consistent Bedtime Routine.

Across groups, mothers supported the need for consistent bedtime routines to support optimal sleep health. Most mothers reported regular nighttime routines to prepare children for sleep. The specific activities included in the bedtime routine differed, but all families supported a need for consistency. One mother of a suboptimal sleeper agreed with the recommendation to have a routine, noting “consistency was key,” but disagreed with having the same timing every night, stating that it was not realistic for all families.

Sleep Duration.

Mothers agreed with the 24-hour duration recommendations for child age. However, a common theme across both groups was either underestimating or being unsure of the child’s nighttime sleep needs. Mothers estimated young child sleep needs somewhere between 7–10 hours at night; however, most mothers were not able to directly state nighttime sleep needs, rather, they estimated by when the child typically slept. Because children were receiving up to a 3-hour nap opportunity at school, most children achieved adequate 24-hour sleep durations. Additionally, across both groups, mothers reported determining the appropriate amount of sleep for their child based on how difficult it was to wake their child in the morning. Barriers to receiving adequate sleep were similar across groups: limited time and needing to get children up early for school. An additional theme of napping as a barrier to earlier bedtimes arose as some children were taking a multi-hour nap at school that mothers reported significantly delayed nighttime sleep onset.

A theme of different sleep patterns on weekends also emerged in both groups, as families endorsed wanting to let children stay up later and allow the family to sleep later on weekends. Most families disagreed with the need for a consistent daily wake time, describing weekend mornings as an opportunity for everyone to catch up on sleep or for mothers to address work/household tasks.

Caffeine Use.

There was no difference in the awareness or avoidance of caffeine by type of sleeper. Most families reported not purchasing sodas as a general health practice. In our small sample, there was slightly more variability in the approaches to caffeine in the suboptimal sleeper group as one family drank tea and one family drank coffee together in the morning as is common in their Puerto Rican culture, despite their awareness that limiting caffeine is recommended. All families acknowledged that limiting caffeine was important in young children.

Co-Sleeping.

In total, 11 families reported currently co-sleeping (5 in the suboptimal group, and 6 in the optimal group), 4 had previously engaged in co-sleeping (3 in the suboptimal group, 1 in the optimal group), and 6 had never engaged in co-sleeping (2 in the suboptimal group, 4 in the optimal group). Perspectives on co-sleeping/bed-sharing were similar between mothers in the optimal and suboptimal sleeper groups. In each group, there was a mix of co-sleeping and non-co-sleeping families, and all mothers identified the benefits and costs of co-sleeping. Mothers across groups identified that co-sleeping could provide comfort to children and mothers while also facilitating child sleep. Mothers also identified negative elements of co-sleeping such as limiting mothers’ space and time to attend to their own needs. Finally, most co-sleeping families reported that this arrangement started to provide comfort and became an undesirable behavior over time, and they perceived transitioning to independent sleep as difficult. For some families, co-sleeping was unintentional as caregivers (mothers or other family members) would fall asleep in their child’s bed due to their exhaustion at the child’s bedtime.

Interest in Intervention.

The majority of families indicated interest in learning more about child sleep (19/20 families endorsed interest; 9 in the optimal group and 10 in the suboptimal sleeper group). Mothers did not have strong preferences for who should deliver the information—most were indifferent or endorsed a range of providers such as doctors, psychologist, researchers, and teachers. More mothers wanted the material delivered in a group format (n=10; 6 in the suboptimal sleeper group, 4 in the optimal sleeper group) than individually (n=6, 2 in the suboptimal sleeper group, 4 in the optimal sleeper group) and 4 endorsed either modality (evenly split between groups). The primary themes that emerged were that the group should be well matched to the current concerns of the family both by child age and by sleep need and that material should be delivered by individuals well versed in child sleep either through personal or professional experience. Mothers expressed some hesitancy in help-seeking due to concerns of being perceived as an inadequate parent.

Discussion

The current study sought to better understand caregiver knowledge of and interest in common evidence-based early childhood sleep recommendations (Allen et al., 2016) to inform sleep health promotion development in an early education setting. We purposefully sampled families meeting quantitative research criteria for optimal and suboptimal sleep based on sleep duration and nighttime awakening frequency. Despite our attempt to purposefully sample families with different sleep health outcomes, maternal perspectives about early childhood sleep health and related recommendations were similar. Although most mothers did not identify a child sleep problem on the quantitative measure, 60% indicated confidence in managing their child’s sleep and mothers showed a moderate amount of sleep knowledge, qualitatively mothers in both groups identified elements of their child’s sleep that they would like to change or have found challenging to address. This finding aligns with research indicating that a much larger proportion of mothers endorse wanting to change elements of their child’s sleep than those endorsing an overall child sleep problem (Mindell et al., 2022).

Programs seeking to promote sleep health in young children should carefully consider how best to identify families in need (i.e., addressing caregiver-perceived sleep “problems” versus desired areas of change) as well as when interventions may be best received. Research definitions relying on duration and night awakenings may miss children who have caregiver-reported behavioral sleep difficulties at bedtime but still obtain adequate sleep and/or have few awakenings, potentially due to family accommodations like co-sleeping. Given the low base rate of caregiver-endorsed child sleep problems in this sample, having interventions available for when families are most in need may be one way to improve utility and uptake. Most mothers expressed interest in child sleep health promotion, which may have been influenced by social desirability, but also reported that matching the timing of the intervention to the family’s current sleep health needs was important when adjusting to having young children. Mothers also expressed hesitancy in help-seeking, suggesting there may be a need for proactive preventative interventions. Finally, families were interested in a group-based format which is consistent with prior qualitative research (Williamson et al., 2020).

The optimal and suboptimal sleepers primarily differed in approaches to managing electronics around sleep. Mothers in the optimal group sought to limit evening electronic access and usage to protect sleep time, while mothers in the suboptimal group used electronics to facilitate sleep and reported more difficulty removing electronics, often reporting concerns that this would negatively impact their child’s sleep. Caregiver beliefs around electronics warrant further study and may be an important point for future interventions. Electronics have previously been described as a barrier to sleep that impacts all domains of sleep such as routines, awakenings, and bedtime resistance (Williamson et al., 2020). Many caregivers endorse having electronics present in the child’s bedroom (Williamson & Mindell, 2020), which can make it challenging to remove electronics from their child’s sleep environment due to either shared sleeping space or mothers’ own use of electronics to facilitate sleep. Screen time has been linked to short sleep duration (Kahn et al., 2021) as well as to externalizing behavior problems—a relationship attenuated with increasing sleep duration (Twenge et al., 2019). Thus, early reliance on electronics to help with sleep onset may result in poor sleep health and adverse behavioral health outcomes over time.

All mothers supported the necessity of sufficient sleep for their child’s development but were unsure about recommendations for healthy age-specific sleep duration. Most mothers reported judging adequate duration by the child’s ability to awaken in the morning, which may serve as an important way to help motivate change in clinical intervention. For example, using a motivational interviewing framework (Miller & Rollnick, 2013), understanding how mothers assess whether their child is rested and the challenges around getting sleepy children ready for their day may help engage families in addressing perceived child sleep difficulties. Despite mothers’ best intentions to get children to bed early, as children aged, the required school nap made bedtime increasingly more challenging. Again, this is an important factor to consider in sleep health promotion interventions, as early childhood educational settings are required to offer naps and if the child falls asleep, mothers may face difficulty at bedtime, especially as child’s sleep needs decrease with age (Eide & Showalter, 2012). For mothers preparing to transition to kindergarten, eliminating a nap opportunity may be an especially helpful practice to facilitate kindergarten readiness. Research indicates that obtaining at least 10 hours of sleep overnight, rather than across the nighttime and daytime, is essential for a successful kindergarten transition (Teti et al., 2022).

Across groups, mothers endorsed the importance of bedtime routines and consistency. Although bedtime routines are central to sleep health promotion interventions, there may be less need to focus on developing and implementing routines as families are aware of their benefits. Similarly, mothers were aware of the impact of caffeine on sleep and most families did not buy soda (with or without caffeine) for the health of their family. Highlighting these areas of strength with families may also be key to engaging families in other behaviors to promote child sleep health.

Co-sleeping families were represented in both the optimal and suboptimal sleeper groups and all mothers identified positive and negative aspects of co-sleeping. Families expressed strong feelings both in support of and against co-sleeping, and for some families cultural and family beliefs also shaped co-sleeping practices. Because of the myriad factors influencing co-sleeping (Peng et al., 2019), a straightforward recommendation (i.e., children should fall asleep alone) is likely to deter families from engaging in any sleep intervention. Rather, co-sleeping is likely best addressed in individual interventions when families identify a shared sleep space and/or caregiver presence at child sleep onset as arrangements that they would like to change (Ramos et al., 2007). Co-sleeping mothers in our sample expressed interest in and worry about difficulties of changing sleep arrangements. More research is needed to attend to the nuances of co-sleeping, recognizing that mothers may simultaneously value some elements of co-sleeping (e.g., connection, ability to check on the child), while also wanting to change for a variety of reasons (e.g., caregiver space, improve caregiver or child sleep, foster child independence).

This mixed-methods study described sleep health practices in primarily Black and Latinx families whose young child attended an early childhood center in a metropolitan environment, which could limit the generalizability. Although there was thematic saturation, this small sample does not represent all caregiver views of young children in similar contexts. Selection biases likely shaped the sample who responded to phone call requests to engage in qualitative interviews. One key limitation of this work was our use of night awakening frequency to differentiate optimal and suboptimal sleepers. Night awakenings are normative, particularly in young children (Tikotzky & Volkovich, 2019), and in this sample did not necessarily correlate with a caregiver-identified child sleep problem, unlike in other research with early childhood samples (Lupini et al., 2022; Williamson et al., 2019b). Of note, we relied on prior research to identify quantitative characteristics of “suboptimal” sleepers. Given that qualitative findings were comparable across the optimal and suboptimal sleep health groups, future research examining poor sleep health in young children should consider other aspects of sleep health as well as caregivers’ perspectives on child sleep patterns to better identify potential differences across these groups. In addition, caregivers in both groups endorsed child sleep problems during the interviews, suggesting that our efforts to apply quantitative criteria developed by researchers to identify poor sleep health may not align with and miss the nuances of families’ perspectives on and experiences with child sleep problems. Caregivers who elected to participate in qualitative interviews may have been more interested in sleep or comfortable with managing their child’s sleep, thus influencing the results. Additionally, despite having fathers and grandparents included in the quantitative study, only mothers elected to participate in qualitative interviews which may have affected the results. Further, as previously mentioned, social desirability may also have influenced what mothers shared during the interviews. Lastly, the use of maternal reports without objective estimates of sleep health parameters, particularly total sleep duration, is also a limitation.

These results highlight the complexities of how families living in lower SES environments perceive common sleep recommendations for early childhood. Sleep is valued but also contextually influenced; thus, sleep health education efforts should be tailored to the needs and values of specific families and communities. Although families generally agreed with common sleep recommendations, they reported variable implementation of such recommendations, making it important for interventions to disentangle the family’s beliefs and daily behaviors from what they believe they “should” be doing. Clinicians and educators should approach sleep health from a culturally humble and family-centered perspective that focuses on aspects of sleep families wish to change, rather than relying on standardized recommendations that lack tailoring to the family environment.

Table 3.

Exemplar Quotes by Sleeper Classification

Sleep Health Domain	Theme	Meta-inference	Optimal Sleep (n=10)	Suboptimal Sleep (n=10)
Electronics Use	Electronics use around bedtime can affect sleep	Caregivers of optimal sleepers actively manage child electronics usage, while caregivers of suboptimal sleepers find electronics usage difficult to control	Cut the tablet off, cut the TV off, we can talk to each other, we can play in our room, but all the like- because I think the TV and the tablet stimulate them more than just playing with each other or even just rough housing throughout the house. (299) … if he has his tablet, he can go all night … I’ll shut off the TV or I’ll take the tablet away- I mean, they’re gonna cry, they’re gonna be upset or have a tantrum, but they’ll get over it and then go straight to bed (28)	[turning off electronics] is the right thing to do you shouldn’t have electronics, you should just [shut] everything off, you gotta put yourself to sleep, and eventually fall asleep. But you have to, as a parent, practice that as well and since I don’t it’s hard to expect her to do it. (140)
Bedtime Routine	Importance of bedtime routines	Caregivers reporting optimal and suboptimal child sleep similarly perceived bedtime routines as important	my son is a child of routine and as long as he has his routine, he’s happily following it. I feel like all kids are actually, because they have a sense of direction, a purpose (28)	Consistency is key. But it’s so unrealistic depending on your lifestyle….. Because it is hard to do the same thing at the same time every day. (6)
Caffeine Use	Limiting caffeine is necessary for young children’s sleep	Optimal and suboptimal sleepers do not generally differ in caregivers’ avoidance of child caffeine consumption	I don’t buy soda at my house because I don’t drink soda… (98)	during the day when they’re here they can have soda like even on the weekend they drink soda and everything but at dinner time when it comes to dinner it’s water and water. (1)
Child Sleep Needs	Child behavior on weekday mornings are an indicator of sufficient sleep	Caregivers of both optimal and suboptimal sleepers are unaware of sleep recommendation guidelines and are generally use child behavior to determine if the child has received enough sleep	When he goes to bed on time, I don’t even have to wake him up. He’s up…But if he goes beyond 9 [bedtime], it’s a wrap. It’s a struggle in the morning so I have to prepare myself…When he sleeps, get a full night’s rest, I don’t have a problem in the morning. He’s up and he’s ready.. (5)	…how I can tell if she’s getting that sleep is … I poke her stomach, and then I poke under her arms, and then I pull her legs on the bed—So, if she laughs, we in a go. But if she’s like, “two more minutes, I’m tired,” if she asks for 2–5 more minutes—I’m like, “oh this is gonna be a hectic morning.” (6)
	Caregivers underestimate sleep needs		How much sleep do you think your three-year-old needs? CG: I wanna say about eight hours. (299)	I think she should get at least 7 or 8 hours of sleep, …it [the recommended sleep duration guideline] just sounds like a lot of sleeping because as an adult I don’t sleep that much (13)
	Naps as a barrier to regular early bedtime	As children get older, required school naps make early bedtimes difficult in both optimal and suboptimal sleepers	I don’t encourage a nap so … it’s easier for me to get him to sleep on time. But once he takes a nap, forget it. (5)	… so, we try to take naptime away…she usually does pretty good 8–10 o’clock you know, sometimes we get her to sleep around 8:30–9 o’clock um, but, otherwise no… (13)
	Limited time as a barrier to sleep duration recommendations	Caregivers of optimal and suboptimal sleepers have difficulty protecting enough time for sleep due to outside demands on time, which could lead to “catch-up” sleep and less consistent schedules on the weekends	I do have late nights at work, so if I’m working late, they’re getting home late cause they’re with Dad and then they have to come home, and nothing’s done at that point. They didn’t have their baths, they probably didn’t eat, so they’re like you know still wound up from the day. So, it does get a little hectic on weeknights. (16)	I don’t agree with putting them in bed at 7. Like I see some of these families and I’m like 7pm?! You get home at 5:30–6 o clock. What time do you spend with them? (44)
	Weekend as a time for all family members to sleep		But he’ll sleep later on the weekends because nobody else gets up, so he’ll get up. There’s no motivation to get up, so they sleep in…And I won’t lie to you, it’s a little bit difficult on the weekends because weekends I already don’t want to budge either. (5) I let them sleep longer on the weekends… I’m not waking them up at 6:00, that’s my time. Just because I’m up doesn’t mean they need to be. (16)	Their dad works late so they kind of at some point around 5 in the morning they migrate to our bedroom in the morning on the weekends…I get up at 6 because I’m usually I’m already working most days. They’re there with him and I try to keep it quiet. I clean, they sleep. It works. (44)
Co-Sleeping	Co-sleeping benefits the family emotionally	Co-sleeping beliefs are complex; caregivers of optimal and suboptimal sleepers similarly identified benefits as well as costs to co-sleeping, and agreed that this practice is challenging to change	You know, so you don’t feel distress. Just tell him go to bed, you know. I’m a nurturing mom, so if [co-sleeping] helps him and it eases him and it helps him with his sleep, that’s what I’m gonna do. (61)	The crazy thing is she has her own room, but she doesn’t sleep in her bed. And then the couple times that we did—were the couple times we were able to put her into bed, I felt some type of way because she cuddles all night…. So, I think at this point, I think we’re both attached. (6)
	Co-sleeping can negatively impact caregivers		First reason is that I need my privacy, and sometimes I don’t go to bed at that time, so I have lights on, I’m talking, you know, so my nighttime routine is important too. (5)	My mom would say don’t [co-sleep], because then what happens is because of work, because I travel, because I like to have a social life, then the baby will suffer because she’s gonna feel the- she’s missing me and another person is not going to babysit because they’re going to be like nah, it’s just gonna be too hard. (289)
	Co-sleeping can be challenging to address		At 0–3 months she was in the bassinet, and then 3 months is when she started coming to the bed. Then I tried to get her out of the bed, but dad would go back and get her and bring her to the bed. Now she’s never going to get accustomed to sleeping by herself if you keep going to get her. “But I want” ‘no leave her be’ like but, nope, every time I try. I even try sleepovers and see If I can get her comfortable by herself. Nope. (146)	My daughter was so tiny and just frail and my husband could not keep her off of his chest.… And that’s why we had so many issues. I know that she’s very strong-willed, but he had a lot to do with it. If I would’ve had it my way, …It’s not so much about you it’s when you’re not around they’re around they’re going to suffer. So that’s the mentality that I had, but my husband did not. (44) at first it was more of a comfort thing because dad and I were really good friends but we kind of separated at that time, so it was really more of a comfort thing, but I don’t-I’m against it only because they don’t know how to kind of let go when it’s time to let go. (13)